The debate in Washington between those who believe universal healthcare equals socialized medicine and the end of the world vs. those who believe that single payer, government mandated health insurance is the only way to stop the selfish evil insurance companies has begun and is gaining steam.
Follow me after the jump...
I believe that single payer universal healthcare is a worthy goal, since I fundamentally believe that good health should be a right and not a privilege. Unfortunately, implementation of it will likely prove to be hard when the reality of the power of the healthcare and pharmaceutical lobbies in Washington are taken into account. They have spent a lot of money and have the ear of key members of congress. I am concerned that there is no appetite for real change, and that fear will instead lead to a doubling down on the status quo.
I have hope that President Obama will walk the walk. However, his actions say otherwise. His willingness to take single payer off the table with out vigorous debate, and his choice of Tom Daschle as HHS secretary and Sanjay Gupta as the surgeon general both speak to his willingness to pay lip service to change while putting in folks who are friendly to the health insurance and pharmaceutical industries respectively. Furthermore, his health advisory team consists of people like Ezekiel Emmanuel who has ties to Humana. I am concerned that health insurance overhaul will mean a further power grab by the insurance companies. If nothing fundamentally changes about how health insurance is delivered, what will stop them from continuing their same practices? They will simply benefit from having more patients to pay premiums. History tells us this is a recipe for disaster for both patients and physicians and a pay day for the insurance companies under the guise of healthcare for all.
I believe the first step should involve a government based public option. This is the only real way to gain the necessary leverage to make the changes needed to improve our health care system. Republicans argue that free market pressure will help patients obtain lower premiums if they are allowed to shop for cheaper health insurance in another state. They neglect to take into account the fact that Blue Cross in Georgia is the same as Blue Cross in Nevada - it is Blue Cross and the company will still shift the cost to the patient in deductibles and rationing of care. Moreover, the insurance companies all operate the same way. I submit that dealing with Aetna or United Healthcare or Blue Cross is the same. They are for profit corporations and their goal is to make as much money for their shareholders as possible. In order to do that they must collect more premiums and pay out as little as possible. There is nothing altruistic about these behemoths.
There is so much wrong with the current system that it needs to be overhauled in order to make it viable. At the current rate we are not training enough primary care physicians, the best and the brightest are choosing not to go into medicine and those who have gone into it because they wanted to care for their patients are leaving the profession because they lack the autonomy to be true advocates for their patient's health and/or they can't afford the cost of doing business.
I am an ear, nose and throat physician in solo private practice. Like physicians practicing today, I have been on the front line and have seen the quality of medicine drop, the cost of medicine increase, and the doctor patient relationship erode. It makes no sense to me that Americans pay more for health care than any other industrial country, but live shorter less healthy lives.
I have come to the conclusion that this down hill slide began to occur in the 90's with the Clinton health care reform fiasco. With Hillary Clinton's acquiescence to the health insurance companies and under the guidance of Ted Kennedy the power of health insurance companies increased. They initiated the model of rationed healthcare under the name ‘HMO’ now known as managed care. As a physician and particularly as a specialist, that was manifested as a 'gate keeper' model that restricted the patient's access to specialty care. I found that patients were kept in the primary care system longer than necessary before referral. For example, they were managed with antibiotics for 6 months before a CT scan was performed when it was obvious that the antibiotics were not working since the symptoms had not resolved. It may have cost the insurance company less in the cost of the antibiotics, but what was the cost to the patient in lost productivity and pain?
When it was obvious that the managed care model was creating a growing number of unhappy patients because of difficulty with timely access to physicians, patient dissatisfaction with the subsequent care, and lack of cost savings because of the need to pay to treat more advanced disease, the model changed to capitation.
Under this arrangement a physician or group was given a certain amount of money per number of patients (covered lives) seen by that the practice. If the cost of caring for those patients was below the amount given by the insurance company then the practice made money. It did not take into account the rising cost of doing business - i.e., supplies, malpractice insurance premiums, salaries for employees or health insurance for employees). This ended because of the untenable pressure on the physician between practicing ethical medicine and bankruptcy.
Now we have evolved to our present situation. The insurance companies have been relentless in shifting the cost of medicine to the patient and the physician. Over the past 10 years I have seen my reimbursements drop every year. Insurance companies have instituted clever ways of cutting reimbursements by instituting: 1) Global days. i.e., the physician cannot charge a patient for up to 90 days after a surgical procedure even though the post operative care may be complete in as little as 10 days. 2) Multiple procedure discounts. In surgical procedures that have more than one step, like an endoscopic sinus surgery, the surgeon will be paid 100% of the discounted amount for the 1st step in the procedure, 50% for the second, 25% for the 3-5 and then nothing after that. In essence this works out to an 80-90% discount; and 3) denial of payment after pre-authorization has been obtained. This means that an in network physician will not get paid for the procedure even though it was pre-authorized. Because of the contract, if the physician losses the appeal the patient cannot be billed because the insurance company has the last say. The patient and employer have also seen a steady increase in premiums and out of pocket deductibles along with less covered services.
It seems obvious that the cost of medicine is driven by the insurance companies. Currently, 30% of the healthcare dollar goes directly to the maintenance of the insurance company. After all it takes money to - hire physicians to deny care, auditors to recoup 'overpayments' to physicians, to purchase new software to edit the medical codes in a way that produce more denials and increases the time that it takes physicians to get paid, and to pay for the feel good commercials that make patients believe that the insurance company is on their side.
The only way to break this cycle is to offer real competition. A non profit government based system will be able to up the ante. Unless the insurance companies compete by both decreasing their premiums and offering more services they will lose patients. This in addition to an emphasis on prevention and wellness is the only REAL way to change our healthcare system to one that is more affordable and of higher quality.